COMMENTARY

Trump Should Get Kudos for Looking at Kidney Dialysis, Transplant

Arthur L. Caplan, PhD

Disclosures

August 30, 2019

This transcript has been edited for clarity.

Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at NYU School of Medicine. President Donald Trump is a lightning rod. He has his fans and his critics, and very few people are neutral about what they think about him.

In the area of healthcare, he has put forward a number of different ideas about how to control prices, what to do about drug costs, and whether he would allow importation of drugs from Canada. Critics from all directions across the political spectrum have said that he has bad ideas, he doesn't know what he's talking about, or his ideas are never going to work.

Today I'd like to praise something that he took an initiative on, in the area of kidney dialysis and kidney transplant. Amidst all the various noise and Sturm und Drang that accompanies the president, you may have missed this.

He made an announcement with Secretary of Health and Human Services (HHS) Alex Azar that said they would like to revisit what's been going on in kidney dialysis and in kidney transplant, to try to improve both. I think that's long overdue. It's very commendable that they've gone there, and morally, it's the right thing to do.

With respect to kidney dialysis, too many people are still getting dialyzed at centers where it's more expensive when they might be able to do dialysis at home. President Trump said he would like to explore whether there is too much utilization of center-based dialysis. Are there cheaper ways to deliver the service? Other countries have pursued more home dialysis rather than having to go into a hospital or a specialized unit. It's a great thing to examine.

He also said that he felt too many people were not being given the option of a kidney transplant. We all know that kidneys are short for transplant, but that doesn't mean many patients couldn't pursue the option of a living donor or a stranger if they wanted to try that.

Financial incentives may have people trapped on dialysis too long. The House has cost this country a large amount of money because there's a special program to pay for it. It's appropriate for the president and the HHS secretary to ask whether we can move more people off of dialysis.

I should add that in my conversations with patients regarding transplant and dialysis, they prefer transplant overwhelmingly. It gives them more freedom. They can eat a bigger diet and live life more fully than they can when they have to be in a dialysis center for 3 hours, three times a week. They would much prefer the freedom and the quality of life that the transplant gives them, even with the need for immunosuppressive drugs.

On the transplant front, President Trump noticed that we lag behind many countries in terms of cadaver organ donation. Furthermore, different parts of the country perform much more poorly than other parts in terms of obtaining organs. That deserves an examination.

I think the whole nation is divided into 52 regions, where organizations are responsible for obtaining organs. Maybe that's too many. Maybe we have too many organ procurement organizations—more than we need. Maybe it would be efficient to consolidate some of these.

Maybe we have to make a bigger effort to get people to think about organ donation when they die than we do currently. Some states trail badly behind others in terms of the percentage of people that do it. There are countries in Europe where there is shifting consent toward a presumption that you want to consent, as opposed to our system where we have to opt in.

I'm not endorsing any of those ideas, but I think all of them deserve a close and careful look. Two cheers for President Trump! Re-examining why dialysis is so expensive in this country and what to do about that, and trying to make the transplant option more available, are really good ideas.

Why did I say "two cheers"? As you know, you can never let a president totally off the hook. There is one area President Trump didn't mention, which I wish he would, and perhaps pressure can be brought to get this back on the table.

Post-transplant coverage for a kidney only lasts 3 years for the drugs you need to prevent rejection, so immunosuppression is only paid for during the first 3 years. That doesn't make sense.

Why would we transplant people and then saddle them with the cost of thousands and thousands of dollars for the drugs? Sometimes we lose those organs because people can't pay or they decide they're going to diminish their own dose because they can't afford it. That is a hole in the system that needs repair.

We should be looking at reimbursement for the medications of people who receive transplants. It's more cost-effective not to have them lose the organs or to cause them to die because they can't afford the immunosuppression 3, 4, or 5 years post-transplant.

So, two cheers and maybe a third coming if we could get the issue of reimbursement for immunosuppressive drugs on the table.

I'm Art Caplan. I'm at the Division of Medical Ethics at NYU School of Medicine. Thanks for watching.

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